Vocal stability in functional dysphonic versus healthy voices at different times of voice loading

Functional (nonorganic) dysphonia is often characterized by vocal instability. The purpose of the prospective study was to examine whether there is a difference in vocal instability of functional dysphonic voices compared with healthy ones, this means whether electroglottographic perturbation values differ (1) between healthy and dysphonic voices and (2) between two subgroups of the dysphponic voices (hpertonic and hypotonic dysphonic voices). Twenty-three patients with hypertonic functional dysphonia, 9 with hypotonic functional dysphonia and 31 healthy nonsmokers, were each examined electroglottographically before (Ex 1), immediately after (Ex 2), and 1 hour after (Ex 3) voice loading. Perturbations of frequency, amplitude, quasi-open-quotient, and contact-index were calculated from the EGG signal. At all three times of examination, hypertonic dysphonic voices showed higher perturbations than healthy voices, and they had higher perturbations than hypotonic dysphonic voices before and 1 hour after voice loading. Hypotonic dysphonic voices showed higher perturbations than healthy voices only 1 hour after voice loading. Voice loading induced different reactions in dysphonic voices: Some voices showed increased perturbations, and others exhibited normal or even decreased perturbation immediately after voice loading. Examination of electroglottographic-derived perturbations immediately after voice loading seems not to be useful. Differentiation of hypertonic and hypotonic dysphonic voices was possible with an estimated sensitivity of 88.9% and a specificity of 87.0% by using the sum of the amplitude-perturbation and the quasi-open-quotient-perturbation measured before voice loading.     

Reliability of Speaking and Maximum Voice Range Measures in Screening for Dysphonia

Speech range profile (SRP) is a graphical display of frequency-intensity occurring interactions during functional speech activity. Few studies have suggested the potential clinical applications of SRP. However, these studies are limited to qualitative case comparisons and vocally healthy participants. The present study aimed to examine the effects of voice disorders on speaking and maximum voice ranges in a group of vocally untrained women. It also aimed to examine whether voice limit measures derived from SRP were as sensitive as those derived from voice range profile (VRP) in distinguishing dysphonic from healthy voices. Ninety dysphonic women with laryngeal pathologies and 35 women with normal voices, who served as controls, participated in this study. Each subject recorded a VRP for her physiological vocal limits. In addition, each subject read aloud the "North Wind and the Sun" passage to record SRP. All the recordings were captured and analyzed by Soundswell's computerized real-time phonetogram Phog 1.0 (Hitech Development AB, T?by, Sweden). The SRPs and the VRPs were compared between the two groups of subjects. Univariate analysis results demonstrated that individual SRP measures were less sensitive than the corresponding VRP measures in discriminating dysphonic from normal voices. However, stepwise logistic regression analyses revealed that the combination of only two SRP measures was almost as effective as a combination of three VRP measures in predicting the presence of dysphonia (overall prediction accuracy: 93.6% for SRP vs 96.0% for VRP). These results suggest that in a busy clinic where quick voice screening results are desirable, SRP can be an acceptable alternate procedure to VRP.     

Multiparametric Evaluation of Dysphonic Severity

SUMMARY: In recent years, the multiparametric approach for evaluating perceptual rating of voice quality has been advocated. This study evaluates the accuracy of predicting perceived overall severity of voice quality with a minimal set of aerodynamic, voice range profile (phonetogram), and acoustic perturbation measures. One hundred and twelve dysphonic persons (93 women and 19 men) with laryngeal pathologies and 41 normal controls (35 women and six men) with normal voices participated in this study. Perceptual severity judgement was carried out by four listeners rating the G (overall grade) parameter of the GRBAS scale. The minimal set of instrumental measures was selected based on the ability of the measure to discriminate between dysphonic and normal voices, and to attain at least a moderate correlation with perceived overall severity. Results indicated that perceived overall severity was best described by maximum phonation time of sustained /a/, peak intraoral pressure of the consonant-vowel /pi/ strings production, voice range profile area, and acoustic jitter. Direct-entry discriminant function analysis revealed that these four voice measures in combination correctly predicted 67.3% of perceived overall severity levels.     

Effect of Dysphonia and Cognitive-Perceptual Listener Strategies on Speech Intelligibility

There is a high prevalence of dysphonia among professional voice users and the impact of the disordered voice on the speaker is well documented. However, there is minimal research on the impact of the disordered voice on the listener. Considering that professional voice users include teachers and air-traffic controllers, among others, it is imperative to determine the impact of a disordered voice on the listener. To address this, the objectives of the current study included: (1) determine whether there are differences in speech intelligibility between individuals with healthy voices and those with dysphonia; (2) understand whether cognitive-perceptual strategies increase speech intelligibility for dysphonic speakers; and (3) determine the relationship between subjective voice quality ratings and speech intelligibility. Sentence stimuli were recorded from 12 speakers with dysphonia and four age- and gender-matched typical, healthy speakers and presented to 129 healthy listeners divided into one of three strategy groups (ie, control, acknowledgement, and listener strategies). Four expert raters also completed a perceptual voice assessment using the Consensus Assessment Perceptual Evaluation of Voice for each speaker. Results indicated that dysphonic voices were significantly less intelligible than healthy voices (P ≤ 0.001) and the use of cognitive-perceptual strategies provided to the listener did not significantly improve speech intelligibility scores (P = 0.602). Using the subjective voice quality ratings, regression analysis found that breathiness was able to predict 41% of the variance associated with number of errors (P = 0.008). Overall results of the study suggest that speakers with dysphonia demonstrate reduced speech intelligibility and that providing the listener with specific strategies may not result in improved intelligibility.     

Evaluating the effectiveness and efficiency of voice therapy using transnasal flexible laryngoscopy: a randomized controlled trial

Transnasal flexible laryngoscopy (TFL) is an examination of laryngeal anatomy and physiology using continuous light. TFL is being used increasingly by voice pathologists in treatment but with little scientific evidence to support it. The purpose of this study was to evaluate the effectiveness and efficiency of TFL as a therapeutic tool. The study used a prospective randomized controlled trial. Fifty dysphonic subjects were recruited and randomly assigned to either a traditional treatment group or a TFL-assisted treatment group. The effectiveness of voice therapy in both treatment groups was measured with a package of voice outcome measures. Subjects in both treatment groups demonstrated statistically significant improvements after voice therapy (perceptual auditory rating of voice quality measurement p < 0.01; instrumental electroglottographic measurement p < 0.01; patient questionnaire measurement p < 0.01). The time taken to complete treatment in both groups was recorded. The average (median) time taken to complete voice therapy in the TFL-assisted treatment group was 2 hours less than in the traditional treatment group (p < 0.01). Voice therapy with TFL as a therapy tool was effective and more efficient than traditional voice therapy.     

Acoustic Prediction of Voice Type in Women with Functional Dysphonia

The categorization of voice into quality type (ie, normal, breathy, hoarse, rough) is often a traditional part of the voice diagnostic. The goal of this study was to assess the contributions of various time and spectral-based acoustic measures to the categorization of voice type for a diverse sample of voices collected from both functionally dysphonic (breathy, hoarse, and rough) (n=83) and normal women (n=51). Before acoustic analyses, 12 judges rated all voice samples for voice quality type. Discriminant analysis, using the modal rating of voice type as the dependent variable, produced a 5-variable model (comprising time and spectral-based measures) that correctly classified voice type with 79.9% accuracy (74.6% classification accuracy on cross-validation). Voice type classification was achieved based on two significant discriminant functions, interpreted as reflecting measures related to "Phonatory Instability" and "F(0) Characteristics." A cepstrum-based measure (CPP/EXP ratio) consistently emerged as a significant factor in predicting voice type; however, variables such as shimmer (RMS dB) and a measure of low- vs. high-frequency spectral energy (the Discrete Fourier Transformation ratio) also added substantially to the accurate profiling and prediction of voice type. The results are interpreted and discussed with respect to the key acoustic characteristics that contributed to the identification of specific voice types, and the value of identifying a subset of time and spectral-based acoustic measures that appear sensitive to a perceptually diverse set of dysphonic voices.     

Vocal loudness and frequency capabilities of the voice

A phonetogram is a graph showing the sound pressure level (SPL) of softest and loudest phonation over the entire fundamental frequency range of a voice. A physiological interpretation of a phonetogram is facilitated if the SPL is measured with a flat frequency curve and if the vowel /a/ is used. It was found that in soft phonation, the SPL is mainly dependent on the amplitude of the fundamental, while in loud phonation, the SPL is mainly determined by overtones. The short-term SPL variation, i.e., the level variation within a tone, was about 5 dB in soft phonation and close to 2 dB in loud phonation. For two normal voices the long-term SPL variation, calculated as the mean standard deviation of SPL for day-to-day variation, was found to be between 2.4 and 3.4 dB in soft and loud phonation. Speakers who raise their loudness of phonation also tend to raise their mean voice fundamental frequency. Measures obtained from speaking at various voice levels were combined so that typical pathways could be introduced into the phonetogram. The average slope of these pathways was 0.3–0.5 st/dB for healthy subjects. Averaged phonetograms for male singers and male nonsingers did not differ significantly, but averaged phonetograms for female singers and female nonsingers did, in that the upper contour was higher for the female singers. Averaged phonetograms for female patients with non-organic dysphonia showed significantly lower SPL values in loudest phonation as compared to healthy female subjects, while no corresponding difference was seen for males in this regard. With respect to the SPL values for softest phonation, male dysphonic patients showed significantly higher SPL values than healthy male subjects, while no corresponding difference was seen in female subjects. The subglottal pressure mirrored these phonetogram differences between healthy and pathological voices. The averaged phonetograms of female patients after voice therapy showed an increased similarity with those of normal voices. For the male patients the averaged phonetogram did not change significantly after therapy.     

The revised Australian fiberscopic profile

The Australian Fiberscopic Profile (AFP) was developed for use in a previous study of normal voices to provide standard documentation for examining the larynx under continuous light. The AFP is being used currently in five specialized voice clinics in Australia to collect data on dysphonic voices. After use with 40 clients it became obvious that a revision with clearer definitions of the parameters was needed to make it a more useful clinical tool.     

Quality of Life in Dysphonic Patients

Voice disorders can affect social life. Dysphonic patients report symptoms of psychological distress as a direct consequence of their dysphonia. It is assumed that their health-related quality of life (HRQL) is reduced. The purpose of this study was to find out whether changes of HRQL depend on the kind of voice disorder (organic or functional) and on the sex of the person affected. A total of 108 adult patients took part in the study, and patients with malignancies were excluded. Test persons were asked to complete the SF-36 questionnaire on their health-related quality of life without prior information about their individual diagnosis. The results of this study show that voice disorders significantly influence patients' HRQL. There are no statistically significant differences between patients suffering from organic and functional voice disorders or between dysphonic women and men. When comparing the results obtained in this study with those in the literature, surprisingly, it seems that the manner in which a person experiences a voice disorder depends on the individual cultural background. Patients with functional voice disorders have similar reduction in HRQL as those with organic voice disorders. HRQL in dysphonic women does not differ from the one in dysphonic men. The results allow for the conclusion that changes of HRQL do not depend on the kind of voice disorder and not on the sex of the person affected.     

Spectral- and Cepstral-Based Measures During Continuous Speech: Capacity to Distinguish Dysphonia and Consistency Within a Speaker

Spectral- and cepstral-based acoustic measures are preferable to time-based measures for accurately representing dysphonic voices during continuous speech. Although these measures show promising relationships to perceptual voice quality ratings, less is known regarding their ability to differentiate normal from dysphonic voice during continuous speech and the consistency of these measures across multiple utterances by the same speaker. The purpose of this study was to determine whether spectral moments of the long-term average spectrum (LTAS) (spectral mean, standard deviation, skewness, and kurtosis) and cepstral peak prominence measures were significantly different for speakers with and without voice disorders when assessed during continuous speech. The consistency of these measures within a speaker across utterances was also addressed. Continuous speech samples from 27 subjects without voice disorders and 27 subjects with mixed voice disorders were acoustically analyzed. In addition, voice samples were perceptually rated for overall severity. Acoustic analyses were performed on three continuous speech stimuli from a reading passage: two full sentences and one constituent phrase. Significant between-group differences were found for both cepstral measures and three LTAS measures (P < 0.001): spectral mean, skewness, and kurtosis. These five measures also showed moderate to strong correlations to overall voice severity. Furthermore, high degrees of within-speaker consistency (correlation coefficients ≥0.89) across utterances with varying length and phonemic content were evidenced for both subject groups.     

Poor Voice Quality in Future Elite Vocal Performers and Professional Voice Users

The voice quality of 86 occupational voice users, i.e., students of a high school for audiovisual communication, was assessed by means of a multidimensional test battery containing: the GRBAS scale, videolaryngostroboscopy, maximum phonation time, jitter, lowest intensity, highest frequency, dysphonia severity index (DSI), and voice handicap index (VHI). In a questionnaire on daily habits the prevalence of smoking, eating habits, and vocal abuse were recorded. A comparison of the voice characteristics of the future occupational voice users with a control group revealed significant differences. The results of the VHI and the DSI of these students revealed significantly worse scores than the score of a control group characterized by no vocal complaints. Moreover, the questionnaire on daily habits showed that the future elite vocal performers and professional voice users take less precautions for the care of their voices. These findings support the importance of a good balanced vocal coaching.     

Vocal quality characteristics in children with cleft palate: a multiparameter approach

The main purpose of the present study was to examine the vocal quality and to investigate the effects of gender on vocal quality in 28 children with a unilateral or bilateral cleft palate. In this study, the vocal quality was determined using videolaryngostroboscopic and perceptual evaluations, aerodynamic, voice range, acoustic, and dysphonia severity index (DSI) measurements. The DSI is based on the weighted combination of four voice measurements and ranges from +5 to -5 for, respectively, normal and severely dysphonic voices. Additional objectives were to compare the vocal quality characteristics of children with cleft palate with the available normative data and to investigate the impact of the cleft type on vocal quality. Gender-related vocal quality differences were found. The male cleft palate children showed an overall vocal quality of +0.62 with the presence of a perceptual slight grade of hoarseness and roughness. The female vocal quality had a DSI value of +2.4 reflecting a perceptually normal voice. Irrespective of the type of cleft, all subjects demonstrated a significantly lower DSI-value in comparison with the available normative data. The results of the present study have provided valuable insights into the vocal quality characteristics of cleft palate children.     

The Prevalence of Voice Disorders Among Day Care Center Teachers Compared with Nurses: A Questionnaire and Clinical Study

The acceptance of voice disorders by day care center teachers as an occupational disease is not an invariably established practice. This is due to the lack of reliable evidence of a higher risk for voice disorders in this profession. To find out the risk of voice disorders, an epidemiological study was conducted among day care center teachers (n = 262), using hospital nurses (n = 108) as a control group. Symptoms were charted by a questionnaire. In a clinical examination made by a laryngologist, the voice quality was assessed and the laryngeal status noted. Teachers at day care centers had significantly more voice disorders than did nurses. Vocal nodules and laryngitis findings appeared significantly more frequently among day care center teachers than among those in the control group. The results prove voice disorders to be more frequent among day care center teachers than among control group subjects, and also that the main cause for this may be a higher vocal loading among day care center teachers than among control group subjects.     

Voice field measurements—a new method of examination: the influence of hearing on the human voice

There are various methods to evaluate voice parameters. Original software was used to assess the voice quality by the staff of AUDIO-Fon centr Brno, Czech Republic. A group of hereditary deaf persons was examined. Deaf persons have all of the biological conditions to make voice except for the possibility of acoustic feedback. We examined the voices of 35 persons (20 men and 15 women) with hereditary profound hearing impairments, and we compared voice parameters with the voice of intact persons. To measure we used special software called voice field measurements (VFMs). The program graphically records voice frequency and intensity. VFM is an objective method that enables the assessment of basic physical voice characteristics. It is suitable for the examination of both intact and disturbed voice. The voice of the deaf has a higher basic voice frequency in men as well as in women. This type of voice production, ie, childlike voice, which is fixed only by a motor stereotype, is much more demanding for a mature larynx. Hearing influences both the voice development and speech production. The voice of persons with hearing impairments has a higher basic voice frequency regardless of their sex. This type of voice production, which is fixed only by a motor stereotype, ie, child voice, is much more demanding for a larynx of an adult. Thus, phonation of deaf people is more demanding and their voice production needs greater effort. Deaf people, despite an intact phonic apparatus, cannot produce more than one type of voice. They cannot modulate their voices concerning the frequency and dynamics. They cannot change their voices continually. The voice is limited in both of these parameters (frequency and dynamics). If a deaf person wants to change a voice characteristic, it is possible only by discontinuous changes-"skipping."     

Acoustic Analysis of Pathological Voices Compressedwith MPEG System

The MPEG-1 Layer 3 compression schema of audio signal, commonly known as mp3, has caused a great impact in recent years as it has reached high compression rates while conserving a high sound quality. Music and speech samples compressed at high bitrates are perceptually indistinguishable from the original samples, but very little was known about how compression acoustically affects the voice signal. A previous work with normal voices showed a high fidelity at high-bitrate compressions both in voice parameters and the amplitude-frequency spectrum. In the present work, dysphonic voices were tested through two studies. In the first study, spectrograms, long-term average spectra (LTAS), and fast Fourier transform (FFT) spectra of compressed and original samples of running speech were compared. In the second study, intensities, formant frequencies, formant bandwidths, and a multidimensional set of voice parameters were tested in a set of sustained phonations. Results showed that compression at high bitrates (96 and 128 kbps) preserved the relevant acoustic properties of the pathological voices. With compressions at lower bitrates, fidelity decreases, introducing some important alterations. Results from both works, Gonzalez and Cervera and this paper, open up the possibility of using MPEG-compression at high bitrates to store or transmit high-quality speech recordings, without altering their acoustic properties.     

Classification of Dysphonic Voice: Acoustic and Auditory-Perceptual Measures

The purpose of this study was (1) to determine the relationship between acoustic measures and auditory-perceptual dimensions of overall voice severity and pleasantness and (2) to evaluate the ability of acoustic and auditory-perceptual measures to discriminate normal from dysphonic voices. Thirty adult dysphonic speakers and six, age-matched normal control speakers were asked to provide oral reading samples of the Rainbow Passage. Acoustic analysis of the speech samples was used to identify abnormal phonatory events associated with dysphonia. The acoustic program calculated long-term average spectral measures, glottal noise measures, and those measures based on linear prediction (LP) modeling. Twelve adult listeners judged overall voice severity and pleasantness from the connected speech samples using direct magnitude estimation (DME) procedures. The acoustic measures accounted for 48% of overall voice severity and 40% of voice pleasantness for dysphonic speakers. The classification performance of the acoustic measures and auditory-perceptual measures was quantified using logistic regression analysis. When acoustic measures or auditory-perceptual measures were considered in isolation, classification was generally accurate and similar across measures. Classification accuracy improved to 100% when acoustic and auditory-perceptual measures were combined. These data provide further support for use of both auditory-perceptual evaluation and acoustic analyses for classifying and evaluating dysphonia.     

Normative Voice Range Profiles of Male and Female Professional Voice Users

Normative voice range profiles (VRP) are calculated for a group of male and female teachers, based on 43 and 46 recordings, respectively. All individuals had healthy voices. These normative VRPs contain 95% prediction intervals for both frequency and intensity. They are based on a series of mathematical transformations of the original individual VRPs in order to maintain in the normative VRPs the typical oval VRP shape, including the dip between modal and falsetto register. The normative VRPs presented are directly applicable in the clinical practice of otolaryngologists and speech-language pathologists.     

The Voice Handicap of Student-Teachers and Risk Factors Perceived to Have a Negative Influence on the Voice

A cross-sectional questionnaire survey was performed. The objectives of the study were to assess the psychosocial impact of current voice complaints as perceived by student-teachers with voice complaints in comparison with student-teachers without voice complaints, and to observe the pattern of risk factors in relation to their voice handicap. Subjects in the general population without a voice-demanding profession were selected as a reference group for limited comparison with the total group of student-teachers (future professional voice users). The respondents to the questionnaires were anonymous. Among the student-teachers, 17.2% reported current voice complaints in comparison with 9.7% of the reference group, and the odds ratio was 1.94, which showed the relative risk. Student-teachers had significantly greater total Voice Handicap Index (VHI) scores than the reference group (P = 0.034). The VHI subscale scores were not significantly different (P > 0.05). Student-teachers who reported current voice complaints had a significantly higher total VHI and subscale scores than student teachers without voice complaints (P < 0.001). Of the student-teachers without voice complaints, 17.0% had VHI scores greater than the 75th percentile. These persons may be neglecting their voice handicap and probably represent the false-negative cases in the estimation of voice complaints. Logistic regression analysis of each of the given risk factors with the VHI as the independent variable showed that the perceived negative influence of the given risk factors on their voices was significantly greater with increasing VHI scores across the VHI range. A significant correlation was observed between the number of perceived risk factors and increasing VHI scores across the VHI range. An increased awareness of risk factors in relation to their voice handicap would serve to motivate student-teachers to change factors that contributed to their voice problem. Attention to all risk factors, which the subjects perceive to be a risk, would aid in effective management of their voice handicap.     

Effects of voice therapy on the voice range profiles of dysphonic patients

In a group of chronically dysphonic patients, a voice range profile, or phonetogram, was recorded before and after receiving voice therapy and again 3 months later. The voice range profiles took a wide variety of shapes. Therefore, only measures that did not depend on a smooth contour could be used to describe changes before and after therapy. The main effect of voice therapy was an enlargement on the side of low frequency and low intensity.     

Pitch strength of normal and dysphonic voices

Two sounds with the same pitch may vary from each other based on saliency of their pitch sensation. This perceptual attribute is called "pitch strength." The study of voice pitch strength may be important in quantifying of normal and pathological qualities. The present study investigated how pitch strength varies across normal and dysphonic voices. A set of voices (vowel /a/) selected from the Kay Elemetrics Disordered Voice Database served as the stimuli. These stimuli demonstrated a wide range of voice quality. Ten listeners judged the pitch strength of these stimuli in an anchored magnitude estimation task. On a given trial, listeners heard three different stimuli. The first stimulus represented very low pitch strength (wide-band noise), the second stimulus consisted of the target voice and the third stimulus represented very high pitch strength (pure tone). Listeners estimated pitch strength of the target voice by positioning a continuous slider labeled with values between 0 and 1, reflecting the two anchor stimuli. Results revealed that listeners can judge pitch strength reliably in dysphonic voices. Moderate to high correlations with perceptual judgments of voice quality suggest that pitch strength may contribute to voice quality judgments.